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Wednesday, May 23, 2012

Death of the Gerontological Nurse Practitioner: Part 1 of 2

The Advanced Practice Registered Nurse Consensus Work Group and the National Council of State Boards of Nursing Advanced Practice Registered Nurses (APRN) Advisory Committee has decided to eliminate the Gerontological Nurse Practitioner track and its associated national certification exam by 2015.

At the University of California, San Francisco (UCSF), this means that the last class of Gerontological Nurse Practitioners (GNP) will graduate in 2013. Starting this fall, incoming UCSF Nurse Practitioner students who wish to focus on the care of older adults will be entering the Adult-Gerontology Primary Care Nurse Practitioner track. This new program will be preparing students to care for persons aged 15 to 105. Geriatric content will be merged into the current Adult Nurse Practitioner program. All graduate schools of nursing who once offered GNP programs are affected by this change.

I am struggling to make sense of this.

Most of us are aware that the population of adults 65 and over is anticipated to reach 70 million by the year 2030. Ten million Americans currently need long term care. This number is projected to rise to 15 million by 2020. Today, there is only one board certified geriatrician for every 2,620 Americans 75 and older. In 2030 there is expected to be only one for every 3,798. Additionally, there is a significant shortage of primary care providers in this country.

This serious gap in the provision of care for the elderly in America can be filled with well-trained nurse practitioners. The Institute of Medicine report on the Future of Nursing specifically speaks to the necessity of nurses to practice at the highest and full extent of their abilities. Gerontological NPs work in long term and transitional care facilities, acute care for the elderly (ACE) units in hospitals, clinics for older adults, home based primary care programs, inpatient and outpatient palliative care, with interdisciplinary teams and in primary practice. Gerontological Nurse Practitioners are in the perfect position to address the primary needs of the aging population.

I imagine that the intent of the new consensus model is to train generalists, generalists who can care for a wide variety of age groups. To that end, it makes sense to add geriatric content to all adult nurse practitioner programs.

However, I’m concerned that the depth and breadth of knowledge necessary to care for the unique needs of older adults cannot be adequately covered within already content packed adult NP programs. How can the new Adult-Gerontology NP track address all the competencies necessary for the care of the adolescent with primary reproductive health needs through the frail elderly with multiple complex chronic conditions and geriatric syndromes within the same time frame? Will Adult-Gerontology NPs be expected to keep up-to-date with all the changes for a population that spans 90 years? Even for the most ambitious, this would be a huge endeavor and no small task for those with only one population focus.

By 2030, one in every five Americans will be 65 or older. Will we all be losing out through the dilution of specialized training for this segment of the population? Are we best served by being generalists? Or is this another health care missed opportunity?

by Patrice Villars

Stay tuned for Part 2 of Death of the Gerontological Nurse Practitioner –perspectives from a graduating GNP student.

21 comments:

Thank you for this article. As a GNP myself, I have the same feelings and thoughts as you. Recently I have been precepting a new Adult-Gero NP student. She is getting all of her gero content in one semester. Let me repeat ONE SEMESTER! I am afraid we not only do a disservice to this already underserved population, I'm actually concerned about what we might be doing to our profession. I look forward to Part 2.

This is a very thoughtful piece.I am understand that any one practicing anything, let alone medical care, needs to have training and education on aging and older adults. I am a GNP my self and see this as a diluting of my profession and I don't think and it will improve health care delivery neither.Thank you,Francisco

Thanks, Patrice, for your thoughtful piece, and yes, the GNPs, like myself, come out of the woodwork, when our rare breed is mentioned in an article like this. I am a UCSF grad ('92) of their GNP program and I have to say it was comprehensive and brilliant and gave me a solid foundation upon which to build my career. Gerontology and geriatrics does, indeed, have its own set of models, best practices, and theories that will likely be attenuated by folding the geri content into the ANP curriculum. Lets hope that the next generation of NPs who are smart enough and lucky enough to PRACTICE GERIATRICS look to us older wiser ones for guidance.

I fully agree. As a Gero CNS, an even rarer specialty- the same change was made. How did this get by us? And how could nursing as a professional body not realize impact of generalist managing healthcare needs of geriatric population? This change is like medicine deciding it doesnt need cardiology as a specialty because everyone has a heart.

Very well written and heartfelt response to the changes ahead. I wonder if this coincides with the push for the Dnp by 2015 across the country to answer the primary care provider role? MD's are not excited about NP's becoming independent in this new role. As nurses we need to pull together and support each other in advanced practice and research. The geri NP is a no brained given the numbers of our aging baby boomers that you have pointed out! I think there may be more to the change in San Francisco's curiculum than meets the eye. I will look forward to part 2!

These were exactly our concerns at the Hartford Foundation four years ago when our colleagues at the American Association of Colleges of Nursing (AACN) shared the news that the gero nurse practitioner program, as part of the national nursing consensus model, was merging with the adult program. Frankly, we were horrified and feared that the program would become “gero lite.”We could not have been more wrong. In 2008, Polly Bednash, Joan Stanley, and Laurie Wilson from the AACN together with Mathy Mezey from the Hartford Institute for Geriatric Nursing at NYU, told us about the dismally low numbers of GNPs—a downward trend that had been going on for years. They convinced us to take advantage of this marriage of the adult and gero because of 1) The potential to educate a much larger pool of nurses about caring for older adults. For example, there are over 240,000 practicing adult NPs but only a small portion—less than 2% specialize in aging.2) And to avoid our fear of “gero-lite” curricular materials and certification exam.

Therefore, in Sept 2008, Hartford made its first of two grants to the AACN (totaling over $850,000) in partnership with the Hartford Institute. As a result, they have created, disseminated, and implemented three sets of Adult-Gero competencies (for the nurse practitioner, clinical nurse specialist, and the critical care nurse) to all schools of nursing. I attended the one of the competency creating meetings and can assure you, gero was more than well represented. And these gero rich competencies will be on the nursing certification exams (Carrots and Sticks, no?).

AACN and the Hartford Institute also developed learning modules, case studies, a PowerPoint slide library, and evidence-based literature reviews to assist faculty in teaching gerontology content. These resources have been disseminated through well-attended faculty development workshops and webinars. All of these tools can be found http://www.aacn.nche.edu/education-resources/competencies-older-adults.

Overall, this grant has been a strategic and timely response to the changing needs of the field. We are grateful to the AACN and Hartford Institute for their tireless efforts to ensure many more nurses will be competent to care for our aging society.

These were exactly our concerns at the Hartford Foundation four years ago when our colleagues at the American Association of Colleges of Nursing (AACN) shared the news that the gero nurse practitioner program, as part of the national nursing consensus model, was merging with the adult program. Frankly, we were horrified and feared that the program would become “gero lite.”We could not have been more wrong.

In 2008, Polly Bednash, Joan Stanley, and Laurie Wilson from the AACN together with Mathy Mezey from the Hartford Institute for Geriatric Nursing at NYU, told us about the dismally low numbers of GNPs—a downward trend that had been going on for years.

They convinced us to take advantage of this marriage of the adult and gero because of 1) The potential to educate a much larger pool of nurses about caring for older adults. For example, there are over 240,000 practicing adult NPs but only a small portion—less than 2% specialize in aging.2) And to avoid our fear of “gero-lite” curricular materials and certification exam.

Therefore, in Sept 2008, Hartford made its first of two grants to the AACN (totaling over $850,000) in partnership with the Hartford Institute. As a result, they have created, disseminated, and implemented three sets of Adult-Gero competencies (for the nurse practitioner, clinical nurse specialist, and the critical care nurse) to all schools of nursing. I attended the one of the competency creating meetings and can assure you, gero was more than well represented. And these gero rich competencies will be on the nursing certification exams (Carrots and Sticks, no?).

AACN and the Hartford Institute also developed learning modules, case studies, a PowerPoint slide library, and evidence-based literature reviews to assist faculty in teaching gerontology content. These resources have been disseminated through well-attended faculty development workshops and webinars. All of these tools can be found http://www.aacn.nche.edu/education-resources/competencies-older-adults.

Overall, this grant has been a strategic and timely response to the changing needs of the field. We are grateful to the AACN and Hartford Institute for their tireless efforts to ensure many more nurses will be competent to care for our aging society.

I am a student in an Adult/Gero Acute Care NP/CNS program. Gero content is "infused" throughout the curriculum, but folks on this blog are right to question whether it is "gero-lite" or not. As an acute care geriatric nurse, the gero content often feels like lip service. Instructors also do not draw specific attention to the gero content unless that is their specific area of interest. Something has been lost.

However, the upside about being an acute/gero NP is that my job opportunities won't be restricted by age. The AACN has moved toward a "setting-specific" model rather than an age group model. This will better prepare NPs to work in many different internal medicine settings, including but not limited to geriatrics. Geriatric patients are seen in all settings by many different primary and acute care providers. Not every setting can afford a specific GNP to provide care--the GNP would need to provide care to young and middle-aged adults as well. The adult/gero model is a more efficient use of the NP role. As someone who is actually interested in gerontology, I know I will seek out opportunities that put me in contact with older adults, probably more so than my colleagues who want to practice in emergency or ICU settings. The program has given me the resources to go deeper into gerontology when I need to, but also the breadth to treat all adult patients, which I suspect will be invaluable.

I can appreciate your concern about job opportunities however as a GNP I am much more concerned about the patients opportunity to receive quality care from an expertly prepared practitioner. This change is reflective of the overall perception that getting older is a step down from the "beautiful" people who have youth on their side. In my opinion The whole rational behind the change exemplifies ageism at its best. If you are a baby or child you are important enough to be treated by someone whose coursework and certification as a PNP ensures a minimum of competence from the practitioner. However if you are part of the Geriatric population, which is as unique and challenging to treat as the pediatric population, specific competence in Geriatrics will no longer be required. Get ready for a whole group of NPs treating gero pts who have no idea of the subtle differences in dementia versus delerium, significant infection w/o a fever, falls heralding more important issues, polypharmacy and the lst goes on......I am just glad I was Gero prepared before this change, i feel so well preared to practice in the field I have such passion for!!!

I suspect that much of this does have to do with the push to DNP - and that it wasn't successfully implemented as necessary for entry to practice. Now, if you were an educator, needing more programs for more students so more educators are in demand, what could you do next? A new program? A requirement that existing NPs must have 400 clinical hours ($$) No matter their previous experience to gain the new and current credential? The powers-that-be don't seem to realize that they are making us look silly professionally and more difficult to employ with all the never-ending changes.

I was alarmed as well when I heard that the consensus model is being utilized to push for an acute care NP- I have to echo what others have said here- it's hard not to think that academia is seeing dollar signs and I will say this ( as a CNS employed in an organization that doesn't recognize my training, so I am now in academia yet again for my FNP), APRNs must take control of this consensus model before more "decisions" like these are written into certification processes! It's curious to me that a social worker is the program manager for the Hartford institute ( no offense)! It would be like NPs directing social work practice. If the grant and the Hartford was influential in the adult-gero NP merger, then Houston I think we have a real problem.

I have most appreciated all of your insightful comments. And I appreciate that many intelligent, creative, and passionate experts put a lot of time and thought into these changes. For me the struggle isn't the GREAT idea of revamping the Adult NP program into one that better incorporates geriatric content, it's that, additionally, those who are 100% committed to working exclusively with older people with have to spend time on content they will not use at the expense of becoming experts (geri-deep) in their chosen area of practice. For those people, why not keep the GNP and let us "limit" our practice? It's what we choose and what, I believe, will most benefit our aging population and changing health care system.

As a 2013 BSN candidate who is set on both earning a higher degree and working with the older adult community, I feel disappointed to read this post. I too echo, why can't we make our own decisions to specialise in what we want to? I had the expectation that I would be able to gratefully focus on my specialty of interest in a master's program. I feel envious of Hector from S. Florida.

Having said that, I do feel happy that more nurses will have a greater scope of knowledge in the care of older adults. I hope that by the time I get into an advanced degree program, that I won't feel jipped or short-changed in the care of older adults.

I am also a GNP by choice. I began to worry in 2006 at the GAPNA conference when they announced their support for adult nps with "experience" to sit for the gero exam. Without of course offering gero NP's the same opportunity. I felt the value and expertise of my degree was devalued by my own specialty organization. No insult is intended toward adult nps. Now, here we are 6 years later and I called my alma mater to check on a bridge for the adult credential and was told the feel content is now integrated into the adult program and I would have to take the entire exam again!! Then to add insult to injury, ANCC sends me a letter valuing my expertise and asking me to field test an exam they say I am not qualified to take. Yes I am insulted, angry, and very cynical about the motives of our elected leaders and organizations. I love my geriatric patients. I don't however intend to support GAPNA, ANCC, or AANP with any more of my money because they have thrown me and my interests under the bus. Ill continue to provide care to my geriatric patients to the best of my ability.

I have been confused and upset about this decision to dismantle GNP programs and integrate them into Adult NP programs for years. As a GNP from one of the last, pure Geriatric/Gerontology programs in 2005, I do not know whether to cry or scream or both. Hector, from Florida, and others you have it right...there will be many, many, many older adults who will unfortunately not benefit from a provider who attended a pure GNP master-level education program.

In the end, the older adults are the ones that will greatly suffer with more missed diagnoses and their usual, unfortunate results, especially in the frail elderly; unnecessary/untimely procedures, operations, etc..; increased ER visits/transfers to acute care; increased and/or extended stays in ACE units and/or rehab/nursing facilities; yes, of course, more polypharmacy; palliative care/hospice...what's that?; poor management, if not out-right aggravation of geri-psych patients - can you just imagine!!; and last, but definately and certainly not least, the LOSS OF HUMANITY OF GROWING OLD and having the specialized care, dignity and respect they deserve in their time of need.

There has always been a stigma and bias around growing old and death/dying in America, both natural occurrences, of course, but now shuting down all APRN Geriatric/Gerontology study/programs across the nation and "throwing them" in with the adult programs definately does nothing but put a large, "rubber stamp of approval" to continue such bias' and stigmas. What this says to me is that older adults or the study of geriatrics itself, is NOT important enough for academia to fight for and the specialization has lost respect - even though the need couldn't be more obvious. Well, if we are going to follow this model than maybe other master-level programs should also be integrated.? How about the NICU program with Pediatrics or Midwifery with Women's Health programs or ICU with Acute programs...the possibilities are endless.

Let's see how far the nursing profession can continue to dis-honor itself and, in this case, our nation's older adults and the study of geriatrics/gerontology itself.

Another example of nursing "shooting itself in the foot." With the aging population growing so rapidly, who would support watering down the pool of advanced practice nurses who are experts in this growing field? (Our own colleagues, apparently.) You can count on the growth of the geriatrics(MD)fellowships. At least they see the trend and act on it. Our profession will regret this decision.

I admire GNPs who applied to APRN programs and knew at the time of their application that they wanted to devote the rest of their careers to caring for older adults. Back in 1990s, I, like many others APRN students, was not quite as focused and did not realize that I would pursue a lifelong career in geriatrics. As an APRN student, it was the older adults that I worked with and the expert teachers and mentors who were passionate about the care of older adults who ignited my interest in geriatrics and helped me to focus on a career path that I still cherish today.

As a clinician, educator, and researcher in the field of geriatrics, some of my most rewarding experiences have come from watching APRN students develop an unexpected interest in caring for older adults. These students describe their ability to make a difference in the lives of older adults and find that the patients' focus on functional and quality of life outcomes are a good fit with their personal philosophy of advanced practice nursing. While I was initially ambivalent about the APRN Consensus Model (2008) transition to a combined adult and gerontological population focus, it has been my experience over the past five years that this new educational framework brings with it the opportunity to expose a greater number of APRN students to geriatrics through more didactic content and clinical experiences with older adults. Not all of the combined adult gerontological APRN students will go on to careers in geriatrics; however, more students are feeling competent in caring for older adults in these combined AGNP programs. In addition, some students who would not have been otherwise exposed to the rewards of a career in geriatrics in adult APRN programs become passionate about the population and eventually make it the focus of their professional careers.

Prior to the APRN consensus model, some state boards of nursing limited the scope of practice of GNPs based on the age of the patient and setting, and many GNPs were seeking additional certification in other NP programs. Practicing APRNs from combined AGNP programs are now experiencing fewer problems in recognition of their role from state to state which is helping with issues of license portability.

Lastly, while gerontology is no longer a specific population focus under the APRN consensus model, care of the older adult must now be taught in many populations (psychiatric mental health, women's health, etc.) that previously provided limited if any geriatric content and exposure. The demographic shift and dramatically increasing ranks of older adults in the US called for a creative solution to the problem of primary care providers who lack geriatric knowledge and expertise. The expected influx of newly insured as a result of the Affordable Care Act is likely to further shift the care of Medicare recipients to APRNs, and the numbers of certified GNPs (3,812 certified according ANCC in June, 2008) is woefully inadequate to meet demand.

Under the Consensus Model, gerontology and care of the frail older adult will now be an APRN specialty whose certification and regulation will be managed by professional organizations. GAPNA is in discussion with other stakeholders about the development of this specialty certification.

As the President of GAPNA, I appreciate the disappointment and frustration that many GNPs are feeling with regard to this change. Moving forward, I would ask everyone to try and keep an open mind. Older adults will need our practicing GNPs to share their expertise, wisdom, and time with the next generation of APRN students and practicing clinicians who may be new to geriatrics. Your mentorship of the next generation of APRNs will improve the care of older adults, their families, and caregivers. For students and APRNs who are new to geriatrics, please keep all of your career options open. No matter where you practice, you will encounter older adults in some capacity and your geriatric clinical experiences and continuing education will make you a more competent and well-rounded provider.

In this day and age to have an arbitrary cut off number to classify an individual as a geriatric or not geriatric does not make sense. Working in the hospital we get patients who are 45 years old that have the body and mind of a 70 year old. On the other hand, we all know 75 year olds who are in better shape mentally and physically than many 40 year olds. What makes one geriatric and not the other?

The Gerontology Primary Care Nurse Practitioner (NP) Competencies, generously supported by the John A. Hartford Foundation and developed in collaboration with the American Association of Colleges of Nursing, the Hartford Institute for Geriatric Nursing at New York University, and the National Organization of Nurse Practitioner Faculties, are an important step forward in response to the 2008 LACE revisions. Not only did we want to have the general LACE framework and competencies, but we also wanted to develop a specific set of expectations and outcomes for adult-gero nurse practitioners who train to become primary care providers. - See more at: http://healthcare-schools.org/gerontology/

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